Beyond the Basics: Choosing the Right Medicare Path for You
Congratulations! If you’ve figured out your Initial Enrollment Period (IEP) and signed up for Original Medicare (Parts A and B), you’ve completed the mandatory first step. But the journey isn’t over. For many, the real decision-making starts now: how do you fill in the coverage gaps left by Original Medicare?
Original Medicare (A and B) covers a large portion of your medically necessary hospital and medical services—but it doesn’t cover everything. You’ll still face deductibles, copayments, coinsurance, and no annual limit on your total out-of-pocket costs under Parts A & B alone. To protect your financial health, you need a plan for the remaining costs and a way to cover your prescriptions.
This is where Medicare becomes a fork in the road. You are now the CEO of your own health and finances: review the facts, understand the trade-offs, and choose the path that offers you the most peace of mind.
Path 1: Original Medicare + Supplements (Medigap)
This path is often called the “Original Medicare” route. You keep your Part A and Part B coverage and add two layers of private insurance to fill the gaps.
Layer 1: Medigap (Medicare Supplement Insurance)
Medigap policies, standardized by the federal government and sold by private companies, are designed to cover your share of the costs in Original Medicare—namely the copayments, coinsurance, and deductibles (the “gaps”).
Key Benefit: Freedom and Predictability. With a Medigap plan you can typically see any doctor or hospital in the U.S. that accepts Medicare, without needing referrals. These plans offer much greater financial predictability: many popular plans, like Plan G, cover nearly 100% of the 20% you would otherwise owe after any deductible for covered services.
Standardized Plans. The plans are standardized with letter designations (Plan G, Plan N, etc.). A Plan G from one company provides the exact same benefits as a Plan G from another. Shop based on price, customer service, and reputation—not just benefits.
The Crucial 6-Month Medigap Open Enrollment Period. You have a six-month open enrollment window during which insurers must offer you any Medigap plan at standard rates and cannot deny you based on health status. That six-month window starts the first day of the month you are 65 or older and are enrolled in Medicare Part B. After this window ends your options may be limited and premiums higher due to underwriting. Some states provide additional protections or extended rights, so check local rules.
Layer 2: Part D (Prescription Drug Coverage)
If you choose the Original Medicare path, you must purchase a separate, standalone Part D plan from a private insurer. Missing your drug-coverage window or going 63 days or more without creditable drug coverage can result in a permanent late-enrollment penalty added to your Part D premium.
Path 2: Medicare Advantage (Part C) – The All-in-One Option
Medicare Advantage (MA) plans, also known as Part C, are an alternative way to get your Medicare benefits. These comprehensive plans are offered by private companies approved by Medicare and replace your Original Medicare coverage.
The “Bundle.” Part C plans typically include Part A + Part B and often Part D (drug) coverage—when they do, they’re called MA-PD plans. They may also offer extra perks that Original Medicare doesn’t cover, such as routine dental, vision, hearing aids, and gym memberships.
Cost vs. Flexibility. Many Medicare Advantage plans have low or even $0 monthly premiums, though you must still pay your Part B premium. Instead of the 20% coinsurance under Original Medicare, you’ll pay copays or coinsurance for almost every service—like $10 for a primary-care visit or $50 for a specialist. Medicare Advantage plans include an annual out-of-pocket maximum (MOOP) for Part A & B services. For 2025 the government limit is $9,350 in-network, though many plans set lower caps. This MOOP doesn’t always include drug or out-of-network costs, so check plan details carefully.
Network Restriction. Most MA plans are either HMOs or PPOs. HMOs require you to use doctors and hospitals within the plan’s network and typically need referrals for specialists. PPOs let you see out-of-network providers for higher costs and may not require referrals. You cannot have a Medigap policy and a Medicare Advantage plan at the same time; you must choose one or the other.
The Drug Component: Part D and the Out-of-Pocket Cap
Prescription-drug coverage is essential no matter which path you choose.
Deductible. You pay 100% of drug costs until you meet your plan’s deductible. For 2026, the standard deductible will be up to $615.
Initial Coverage. After meeting the deductible, you pay copayments or coinsurance according to your plan’s drug tier, and your plan pays the rest. This phase lasts until total drug spending by you and your plan hits a set threshold.
Out-of-Pocket Cap. Thanks to the Inflation Reduction Act, there is now a hard cap on what you’ll pay out-of-pocket for covered drugs. In 2025, the cap is $2,000; in 2026 it’s projected to rise to $2,100. Once you reach that limit, you pay nothing for covered medications for the rest of the year.
Action Step. Even if you choose a Medicare Advantage plan with drug coverage, check the plan’s formulary to ensure your prescriptions are covered and verify which cost tier they fall under.
You’re the CEO of Your Health Coverage
There’s no universally “better” path—only the right one for you.
Choose Path 1 (Original + Medigap + Part D) if you value the freedom to see nearly any doctor or hospital nationwide, want the lowest possible out-of-pocket costs, and can budget for higher monthly premiums.
Choose Path 2 (Medicare Advantage – Part C) if you prefer lower or $0 monthly premiums, are comfortable using a provider network, and appreciate added benefits like dental and vision.
Additional Key Points and Clarifications
Original Medicare (Parts A & B) has no annual out-of-pocket cap, so high medical bills can add up quickly without supplemental coverage. Medigap rules and premiums vary by state. Federal law guarantees a six-month open enrollment when you’re 65 and enrolled in Part B, but states may add protections—especially for people under 65 who qualify for Medicare due to disability.
Even with Medigap, you’ll still need separate coverage for routine dental, vision, hearing aids, and long-term care. With Medicare Advantage, always confirm that your doctors and hospitals are in-network, since networks can change annually.
Enrollment periods to know:
- Initial Enrollment Period (IEP): 7 months (3 months before, your birth month, and 3 months after you turn 65).
- Annual Enrollment Period (AEP): October 15 – December 7 each year, when you can switch plans.
- Medicare Advantage Open Enrollment: January 1 – March 31, when current MA members can change or drop coverage.
Missing drug coverage (Part D or an MA-PD) can lead to a lifetime penalty. For 2025, the standard Part B premium will be $185/month with a deductible of $257.
Final Thoughts
This journey isn’t just about getting enrolled—it’s about planning strategically. Start by mapping your typical healthcare use: do you travel often, need specialists, or take regular prescriptions? Then compare premiums, cost-sharing, provider flexibility, and extra benefits. Decide whether you value maximum flexibility (Original Medicare + Medigap) or bundled simplicity (Medicare Advantage).
Use the official Medicare Plan Finder to review your options annually and ensure your coverage still meets your needs.
Don’t wait until it’s too late; start your estate planning journey with Gentreo today. By doing so, you’ll not only protect your loved ones but also gain the peace of mind that comes with knowing your legacy is secure. Click HERE to join now.
This article is for informational purposes only and should not be considered legal advice. Consult with a qualified attorney or estate planning professional for personalized guidance.
